Thoracoabdominal Aortic Dissection Research Articles

Possible graft-related complications in visceral debranching for hybrid B dissection repair.

Hybrid repair (HR) of thoracoabdominal aortic aneurysm (TAAA) and dissection (TAAD), consisting of rerouting renovisceral branches followed by endograft aortic repair, has been shown to be a feasible option. It is especially appealing in patients unfit for both open and total endovascular repair. In order to determine the role of dissecting etiology and intraoperative variables as risk factors for graft-related complications in visceral debranching, we retrospectively analyzed the clinical outcomes, patency rate and hemodynamic alterations of the renovisceral debranching grafts in our series. We analyzed 55 consecutive patients who underwent thoracoabdominal aortic HR between 2001 and 2013 in our center. Forty-four procedures were performed for TAAA and 11 procedures for TAAD. In TAAD patients, dissection involved 9/44 (20.5%) renovisceral vessels. One hundred and fifty-nine visceral bypasses were made (156 retrograde; three anterograde). Thirty-day mortality was 12.7% (n=7). Potential graft-related complications included four cases of pancreatitis (7.3%) and five of peri-operative renal failure (9.1%). At a mean follow-up of 36.1 months, the global rate of visceral graft occlusion was 9.4% (15/159), leading to fatal bowel infarction in two patients and kidney loss in seven patients. Actuarial primary patency in renovisceral grafts at 12, 24, and 36 months was 96.3%, 92.6%, and 90.2% respectively. At the level of the anastomosis of the graft to the superior mesenteric artery, significant flow alterations (systolic peak velocity >250 cm/s) were observed during computed flow dynamics analysis in 18.5% of cases. Overall, an additional procedure to ensure patency was required in 19 bypasses intraoperatively and three during follow-up. The presence of aortic dissection had no significant impact on debranching graft-related complications. During multivariate analysis, retropancreatic routing to CT was the only independent predictor of graft-related complications (P=0.006). Specific visceral graft-related complications were not uncommon in our series and were often associated with clinical consequences. Hemodynamic alterations of debranching grafts were observed in particular at the level of the anastomosis with the superior mesenteric artery. Careful follow-up is mandatory in order to monitor visceral bypasses and facilitate patency when required.

Long-term outcomes in thoracoabdominal aortic aneurysm repair for chronic type B dissection.

Open repair for chronic aortic dissection remains a challenging surgical option. Different centers report diverse experiences and outcomes pertaining to thoracoabdominal aortic aneurysm repair (TAAAR) for chronic type B dissection. We highlight our center's experience and results on a background of published literature and current evidence. We reviewed 214 open TAAAR performed between October 1998 and February 2014. Of these, chronic type B dissection was present in 62 (29.0%) patients. We reviewed these patients in terms of demographics, operative characteristics and outcomes. Thirteen (21.0%) patients had surgery on the descending thoracic aorta [Category A =2 (3.2%), B =0 (0%), C =11 (17.7%)] and 49 (79.0%) in the thoracoabdominal thoracic aorta [Crawford extent I =5 (8.1%), extent II =39 (62.9%), extent III =4 (6.5%), extent IV =1 (1.6%)]. Left heart bypass was used in 12 (19.4%) patients. The composite in-hospital endpoint, adverse outcome-defined as operative death, renal failure necessitating dialysis at discharge, stroke, or permanent paraplegia or paraparesis-occurred after 28 (45.2%) procedures. There were 14 (22.6%) operative deaths. In-hospital mortality was seven (16.3%) out of 43 elective patients, and increased to seven (36.8%) of the 19 non-elective ones. Permanent paraplegia or paraparesis occurred after two (3.2%) cases, stroke occurred after seven (11.3%) and renal failure requiring dialysis occurred after 16 (25.8%). Mean follow-up time was 3.2 years and actuarial 5-year mortality was 27.4% [nine (14.5%) elective and eight (12.9%) non-elective patients]. TAAAR in chronic type B dissection carries a substantial risk of early adverse outcomes. The results could be well alleviated with cases directed towards specialized regional and supra-regional centers. Although the endovascular approaches offer relatively low mortality and morbidity, there is a lack of long-term data and guidelines on their use. There is a need for a multidisciplinary international registry on the management of thoracoabdominal aortic aneurysms and dissection. This would provide a degree of guidance on relevant clinical and surgical judgments and outcomes.

When Not to Implant the Multilayer Flow Modulator: Lessons Learned From Application Outside the Indications for Use in Patients With Thoracoabdominal Pathologies

To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes. Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation >6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR). Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.0±6.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.12±0.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p=0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p=0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p<0.002, HR 4.02, 95% CI 1.70 to 9.49). There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

Population-Based Study of Incidence and Outcome of Acute Aortic Dissection and Premorbid Risk Factor Control

Background— Acute aortic dissection is a preventable life-threatening condition. However, there have been no prospective population-based studies of incidence or outcome to inform an understanding of risk factors, strategies for prevention, or projections for future clinical service provision. Methods and Results— We prospectively determined incidence and outcomes of all acute aortic dissections in a population of 92 728 in Oxfordshire, United Kingdom, from 2002 to 2012. Among 155 patients with 174 acute aortic events, 54 patients had 59 thoracoabdominal aortic dissections (52 incident events: 6/100 000, 95% confidence interval, 4–7; 37 Stanford type A, 15 Stanford type B; 31 men, mean age=72.0 years). Among patients with type A incident events, 18 (48.6%) died before hospital assessment (61.1% women). The 30-day fatality rate was 47.4% for patients with type A dissections who survived to hospital admission and 13.3% for patients with type B dissections, although subsequent 5-year survival rates were high (85.7% for type A; 83.3% for type B). Even though 67.3% of patients were on antihypertensive drugs, 46.0% of all patients had at least 1 systolic BP ≥180 mm Hg in their primary care records over the preceding 5 years, and the proportion of blood pressures in the hypertensive range (&gt;140/90 mm Hg) averaged 56.0%. Premorbid blood pressure was higher in patients with type A dissections that were immediately fatal than in those who survived to admission (mean/standard deviation pre-event systolic blood pressure=151.2/19.3 versus 137.9/17.9; P &lt;0.001). Conclusions— Uncontrolled hypertension remains the most significant treatable risk factor for acute aortic dissection. Prospective population-based ascertainment showed that hospital-based registries will underestimate not only incidence and case fatality, but also the association with premorbid hypertension.

Hybrid procedures for thoracoabdominal aortic pathologies

We report our three-year experience with the visceral hybrid procedure for patients with thoracoabdominal aortic aneurysms, dissections and Takayasu's arteritis. We also evaluate and discuss the outcomes of hybrid procedures. Hybrid procedures include debranching of the visceral or renal arteries followed by endovascular repair of the disease. The surgical strategy was designed individually to reduce trauma and minimize stent coverage area. A series of 11 patients (9 men, mean age 52 years) were treated between June 2008 and September 2011. The pathologies were aneurysmal disease (thoracoabdominal aortic aneurysms) (5, 45.5%), aortic dissection (thoracoabdominal aortic dissection) (4, 36.4%) or true/false aneurysm formation after Takayasu's arteritis (2, 18.2%). Simultaneous approach (9, 81.8%) and staged approach (2, 18.2%) were performed. The mean follow-up was 13.5 months (range 1–36). The technical success was 100%. Stent grafts were implanted in the entire or part of the thoracoabdominal aorta. The overall mortality rate was 9.1% (1/11) with no aneurysm-related death. The permanent paraplegia and bypass graft occlusion rate was 0%. The overall morbidity was 36.4% with two endoleaks (2/11, 18.2%). In conclusion, hybrid procedures can minimize surgical invasiveness in treatments of thoracoabdominal aortic pathologies, and it is a safe method with acceptable morbidity and mortality.

Hybrid procedures for thoracoabdominal aortic aneurysms and dissections

Background Hybrid procedures including debranching of visceral and renal arteries followed by endovascular exclusion of the thoracoabdominal aortic aneurysm (TAAA) have recently been proposed as a less invasive alternative to conventional TAAA surgery. This study aimed to evaluate the immediate and long-term outcomes of hybrid procedures for TAAA in high-risk patients. Methods Between September 1998 and May 2012, 32 high-risk TAAA patients (five females, median age 61.5 years) underwent hybrid procedures at a single institution. Simultaneous approach and staged approach were performed on the basis of patients' conditions. Follow-up computed tomography angiography (CTA) was routinely performed before discharge and at 6, 12 months and annually thereafter. Results Procedural success was achieved in all cases. The median hospital stay was (21.5P2.3) days, and the median procedure time was (420231) minutes. Blood loss averaged (21003261) ml. A total of 124 visceral artery bypasses was performed. Two patients (6.3%) died within 30 days. One patient exhibited complete paraplegia (3.1%). The visceral graft patency was 96.1% at 3 years. All-cause survival rates were 93.8%, 87.5%, 81.3% and 53.1% at 1, 2, 3 and 5 years, respectively. No patient died due to aortic events. The freedom rates from aortic events were 96.9%, 93.6%, 87.5%, 68.8% at 1, 2, 3 and 5 years, respectively. Conclusions The results of visceral hybrid repair for high-risk patients with complex TAAAs are encouraging. However, the procedure is still a significant physiological insult to patients. Until branched and fenestrated endovascular repair become more common, hybrid procedure will continue to have a role in high-risk patients.

Successful Kidney Transplantation for End-Stage Renal Disease in Marfan's Syndrome.

Marfan's syndrome is a systemic disorder of the connective tissue caused by mutations in the extracellular matrix protein fibrillin-1, with aortic dissection and aneurysm being its most life-threatening manifestations. Kidney transplantation for end-stage renal disease (ESRD) in patients with Marfan's syndrome has not been reported in the literature, and the rate of the incidence of dissection or aneurysm in the iliac artery is unknown. Here, we present a patient with Marfan's syndrome with ESRD due to severe renal ischemia caused by massive bleeding from thoracoabdominal aortic dissection leading to transplant surgery of a living kidney procured from the patient's mother. After kidney transplantation, the renal function normalized without vascular complications, and stable graft function along with negative results for both microhematuria and proteinuria continued for two years. Also, vascular complication such as aneurysm or dissection of the iliac artery was not observed using ultrasonography during the follow-up period. ESRD patients with Marfan's syndrome might be suitable for kidney transplantation, but long-term and careful observations are needed.

Thoracic Aortic Dissection and Thoracoabdominal Acute Type B Aortic Dissections Have Superior Survival When Treated With Thoracic Endovascular Aneurysm Repair and Open Surgery Compared to Medical Therapy: Outcomes from the National Medicare Database

Objective(s): This study evaluated short-term and long-term outcomes for the management of type B thoracic aortic dissection (TAD) and thoracoabdominal aortic dissection (TAAD) based on initial treatment modality as well as interval therapy in the Medicare national database. Methods: The Medicare Beneficiary Database (2005-2008) was used to identify patients who underwent treatment of type B TAD or TAAD. Comorbidities, 30-day and long-term mortality, therapy conversion, and complications were recorded. Statistical analysis for categoric variables were compared with 2 and continuous variables with t test. Propensity score evaluation was performed for comparison of treatment groups with similar comordities. Results: Treatment in 10,041 patients was medical in 8413 (84%), open surgical in 1222 (12%), or thoracic endovascular aneurysm repair (TEVAR) in 406 (4%). Patients who received medical therapy were older than open or TEVAR patients (76 vs 72 vs 71 years) and had higher rates of cardiac, renal failure, and hypertension. The 30-day mortality was 23.5% for medical, 21.2% for open, and 11.9% for TEVAR. During the index hospitalization, the open group had significantly greater rates of cardiac, renal, bleeding, and pulmonary complications. Initial medical therapywas converted toTEVARin2.5%andtoopenrepair in2.3%.Open repair was converted to TEVAR in 0.5% and redo open in 1.0%. TEVAR required redo TEVAR in 2.7% and open in 1.6%. Long-term survival was improved for TEVAR and open repair compared with medical therapy (Fig). Propensity score evaluation revealed significant survival advantage at 1000 days for TEVAR (P .0006) and open repair (P .0059) compared with medical therapy. Conclusions: Patients undergoing TEVAR have a significantly improved short-term survival, and open surgical and TEVAR repair have a significantly improved long-term survival compared with the medical management of type B TAD and TAAD. When patient groups with similar comordities are compared using a propensity score, there is even a greater advantage for TEVAR and open repair compared with medical management. Further evaluation will be required to validate this observation.

Open Repair of Descending and Thoracoabdominal Aortic Aneurysms and Dissections in Patients Aged Younger Than 60 Years: Superior to Endovascular Repair?

The best option for repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAA)-whether open operation or stent grafting-is increasingly a subject of controversy. We examined the results of open surgical repair in patients aged 60 years or younger to assess the value of conventional repair in younger patients. From October 2002 to October 2010, 107 of 294 TAAA operations were in patients (75 men [70%]) aged a mean of 48 ± 9 years. Twelve patients (11%) had Marfan syndrome. Operations were elective in 101 (94%); previous aortic operations had been performed in 40 (37%). The most common indication for operation was chronic dissection, in 60 (56%); 5 (4.7%) had acute dissection, and rupture was present in 6 (5.6%). Descending repair was undertaken in 44 (41%), in 32 (73%) as an elephant trunk stage II. Deep hypothermic circulatory arrest was used in 46 (42.9%). Neurologic monitoring and cerebrospinal fluid drainage were routine. Median postoperative follow-up was 4.3 years (range, 2 days to 7.9 years). Overall 30-day mortality was 4.7%. Stroke occurred in 4 patients (3.7%) and paraplegia in 1 (0.9%). The linearized rate for reoperation for TAAA was 0.22/100 patient-years (1 patient in 448.8 patient-years). Survival at 1, 5, and 8 years was 90.5%, 89.4% and 80.5%, respectively. During follow-up, 1 patient with Ehlers-Danlos died of aortic complications at 4.5 years. Although direct comparison with stent grafting is limited by the diversity of patients and indications in published reports, our results suggest that open repair should be the modality of choice. Early mortality and neurologic complication rates are similar, if not superior, to endovascular repair for descending aortic and TAAAs. Open repair has proven durability and a very low rate of required reintervention, in contrast with endovascular repair.

Open Repair of Chronic Aortic Dissections Using Deep Hypothermia and Circulatory Arrest

There has been great enthusiasm for thoracic endograft repair of chronic thoracic or thoracoabdominal aortic dissection (ChAD) given the low operative morbidity and mortality. However long-term results are unknown and early reintervention is common. This study examines the early and late results of open repair of ChAD using deep hypothermia and circulatory arrest (DHCA). From January 1995 to December 2009, 343 patients had open repair of descending thoracic or thoracoabdominal aneurysms using DHCA. Of these individuals, 93 patients had open repair of ChAD with DHCA. All patients undergoing elective procedures underwent preoperative cardiac catheterization. Lumbar drains were not placed preoperatively. Visceral or renal artery bypass was performed in 20% of patients. Supraaortic branches were bypassed in 14% of patients. Mean age was 60 ± 14 years. Men composed 77% of the cohort. Aortic replacement encompassed the descending aorta in 29% of patients, type I thoracoabdominal repair was performed in 25% of patients, type II thoracoabdominal repair was performed in 40% of patients, and arch replacement was performed in 24% of patients. Operative mortality was 2.2%, renal failure requiring dialysis was 0%, paralysis occurred in 1.1% of patients, stroke occurred in 1.1% of patients, prolonged intubation was needed in 9.7% of patients, and tracheostomy was needed in 2.2% of patients. Postoperative length of stay was 10.5 ± 7.6 days. One-, 3-, 5-, and 10-year survival rates were 93%, 90%, 79%, and 61%, respectively. Reintervention was necessary in 2.2% of patients for graft infection, in 2.2% of patients for anastomotic pseudoaneurysm, and in 4.4% of patients for growth of a distal aortic aneurysm. Open repair of ChAD with DHCA has low operative morbidity and mortality. Long-term survival is very good with low rates of reintervention. Endovascular repair of ChAD does not have proven short- or long-term efficacy.

Open repair of chronic distal aortic dissection in the endovascular era: Implications for disease management

Controversy surrounds the treatment of chronic aortic dissection. Open surgical and endovascular experiences include mixed populations treated with evolving strategies and limited follow-up. We establish a standard against which endovascular repair can be compared by assessing outcomes after open repair of chronic distal aortic dissections anatomically suitable to stent-grafting. From 2000 to 2008, 169 patients underwent open repair of the descending thoracic artery only (n=88) or thoracoabdominal (n=81) chronic aortic dissection (elective in 98, urgent/emergency in 71). Chart review and 3-dimensional assessment of computed tomography were performed. Poor outcome included all-cause mortality or vascular reintervention. Thirty-day mortality was 8% (n=14). Serious complications included neurologic (n=12 [spinal cord n=4, 2.4%]), respiratory (n=32), and renal failure (n=1 descending thoracic artery only vs 17 thoracoabdominal, P<.001). Chronic obstructive pulmonary disease predicted early mortality (hazard ratio 8.0, P=.005). Survival at 1, 2, and 5 years was 76%, 69%, and 55%, respectively; 23 patients (14%) required reintervention. Event-free survival at 5 years was 51% and 47% after descending thoracic artery only or thoracoabdominal repair, respectively. Greater maximum aortic diameter (hazard ratio 1.9, P=.03) and greater diameter at the diaphragm (hazard ratio 3.7, P=.01) or renal segment (hazard ratio 4.3, P=.03) predicted poor outcome. Early outcomes are good and late outcomes are less than desirable after open repair of chronic distal aortic dissection, regardless of the extent of repair. High-risk and late-stage patients with larger and more extensive aneurysmal degeneration warrant further investigation, including the use of newer, less-invasive techniques. Select patients at risk for aneurysmal degeneration should undergo a more aggressive initial approach with aortic dissection repair.

Dissection of thoraco-abdominal aorta following stenting for coarctation

Dissection of thoraco-abdominal aorta following stenting for coarctation

Adjunctive Endovascular Techniques in Management of Acute and Chronic Type B Thoracoabdominal Aortic Dissections: Implications of False Lumen Thrombosis, Pressurization, and Remodeling

Objectives: We evaluated the impact of inducing false lumen (FL) thrombosis via coil embolization during repair of type B thoracoabdominal aortic (TAA) dissections. Methods: Since 2007, 26 patients underwent treatment of type B TAA dissections for aneurysm formation (n = 18, 69%), unremitting pain (n = 11, 42%), or rupture (n = 6, 27%). All thoracic endovascular aneurysm repair (n = 21, 81%) and endovascular aneurysm repair (n = 6, 19%) patients underwent coverage of all fenestrations along the descending thoracic aorta or the infrarenal aorta/iliac arteries. During the procedures, transfemoral access was obtained into both true lumen and FL; the stent grafts were implanted in the true lumen, and a cardioMEMS Endosure wireless pressure sensor as well as coils were packed in the FL of the thoracic or abdominal aorta/iliac arteries. The ratio of “FL to systemic pressure” measurements were recorded at systolic, diastolic, mean, and pulse pressure index at the time of implantation, at 1 month and every 6 months thereafter, and computed tomography angiography (CTA) was obtained at similar intervals. Results: Technical success was obtained in all procedures; completion arteriogram did not indicate contrast filling into the FL. Follow-up 6-month and 1-year CTA indicated several significant findings: marked FL thrombosis in 22 patients (85%), FL remodeling with >5-mm reduction in maximum diameter in 17 patients (65%), and none of the patients had an increase in FL maximum diameter. All systolic, diastolic, mean, and pulse pressure index ratios of “FL to systemic pressures” were significantly reduced in 23 patients (88%) at 6 months and 1 year. No patients developed spinal cord ischemia, there were no significant outcome differences in acute and chronic TAA dissections, and the 30-day mortality was 3.8%. Conclusions: FL embolization during endovascular management of acute and chronic type B TAA dissections is safe and effective in reducing FL pressures and maximum diameter and can be a valuable alternative in management of high-risk TAA patients.

Aortic dissection in young adults who abuse amphetamines

Case reports suggest a relationship between amphetamine abuse/dependence and aortic dissection, but no population-based epidemiologic studies have examined this link. Our objective was to test the hypothesis that young adults with a diagnosis of amphetamine abuse/dependence would be at higher risk for aortic dissection after accounting for known risk factors. In this population-based case-control study of 30,922,098 discharges from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1995 to 2007, among persons aged 18 to 49 years, we identified 3,116 thoracic and thoracoabdominal aortic dissections using International Classification of Disease, Ninth Edition, Clinical Modification codes 441.01 and 441.03. The SURVEYLOGISTIC procedure in SAS 9.2 (SAS Institute, Cary, NC) was used to account for the Nationwide Inpatient Sample sampling methodology. In a multiple logistic regression analysis, while controlling for known risk factors, amphetamine abuse/dependence was significantly associated with aortic dissection (adjusted odds ratio = 3.33, 95% CI = 2.37-4.69, P < .0001). This statistically significant association suggests that amphetamine abuse/dependence may play a role in aortic dissection in young adults in the United States.

Open and endovascular repair of type B aortic dissection in the Nationwide Inpatient Sample

The use of stent grafts and mortality of stent graft repair of type B thoracic aortic dissection (T(B)AD) is not well defined. We sought to determine national estimates for the use and mortality of thoracic endovascular aortic repair (TEVAR) for T(B)AD in the United States. Records of the Nationwide Inpatient Sample (NIS) database between 2005 and 2007 were examined. International Classification of Diseases, 9th edition (ICD-9) diagnosis codes were used to select patients who underwent open or TEVAR with a stent graft for a diagnosis of thoracic aortic dissection or thoracoabdominal aortic dissection. We excluded patients with a diagnosis code for aortic aneurysm and those with procedure codes for cardioplegia or for operations on heart vessels or valves, which were considered type A dissections (T(A)AD). The remaining patients were considered as T(B)AD. We compared demographics and comorbidities, as well as adjusted complications and mortality rates, between patients undergoing TEVAR vs open repair. We identified an estimated 10,466 repairs for dissection of the thoracic or thoracoabdominal aorta (open, 8659; TEVAR, 1818). Of these, 464 had a diagnosis of aortic aneurysm, and 5002 patients were considered T(A)AD. Of nonaneurysmal dissections, 5000 repairs were considered T(B)AD (open, 3619; TEVAR, 1381). The endovascular patients were older and had greater comorbidities, although only cardiac disease, renal failure, hypertension, and peripheral vascular disease were statistically significant. In-hospital mortality was 19% for open repair vs 10.6% for TEVAR (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.36-3.67; P < .01). In-hospital mortality was significantly higher with open repairs coded as emergent admissions (20.1% vs 13.1%; P = .03), but did not reach statistical significance for elective admissions (12.3% vs 4.8%; P = .09). Cardiac complications (12.4% vs 4.9%, P < .01), respiratory complications (7.7% vs 4.3%, P = .02), genitourinary complications (9.0% vs 2.5%, P < .01), hemorrhage (14.0% vs 2.8%, P < .01), and acute renal failure (32.1% vs 17.2%, P < .01) were more frequent in the open repair group. Median length of stay was greater in the open repair group (10.7 vs 8.3 days, P < .01). For patients with a diagnosis of T(B)AD who undergo repair, the endovascular approach is being used for older patients with greater comorbidities, yet has reduced morbidity and in-hospital mortality. The use of endovascular stent graft repair for type B thoracic aortic dissection merits further longitudinal analysis.

Thoraco-abdominal aortic conventional surgery in elderly population

BackgroundThoraco-abdominal aortic pathologies are universallyconsidered as lethal conditions. The most prevalentetiology is atherosclerotic or degenerative but otheretiologies such as mycotic, post-traumatic, connectivetissue disease-related and dissection-related are alsoencountered. The estimated actuarial 1-year and 5-yearsurvival rates in patients with thoraco-abdominal aorticaneurysm is 60% and 20% respectively in untreatedpatients [1,2]. The prognosis, with or without treatment,is complicated by high incidence of comorbidities and isstrictly related with a predominantly elderly population.Since the early ’90s many Authors have investigated theefficacy of endovascular treatment in the treatment ofthoracic and thoraco-abdominal aortic aneurysms and/or complicated aortic dissections. On this basis webelieve that conventional surgery may be reserved alsoin patients over 70 years-old in absence of severepreoperative comorbidities such as chronic obstructivepulmonary disease, renal insufficiency, coronary arterydisease, cerebral vasculopathy.Our surgical approach involves graft replacementbetween the distal aortic arch and the descending thor-acic aorta through a left posterolateral thoracotomy pre-paring proximal and distal aortic cuffs using biologicalglues and external strips of Teflon felt to reinforce thewall. Moreover cerebrospinal fluid drainage by acatheter inserted at the level of L3 or L4 to maintain apressure of 10 mmHg or below and perfusion of thedistal aorta using femoro-femoral bypass is performed.All patients are positioned on the operating table in thelateral position with the abdomen and the pelvis turnedso that the groin was at a 45 angle to the table to allowcannulation of the femoral vessels.In a preliminary study comparing endovascular andconventional surgery treatments in patients with acutetype B aortic dissection, the early results regarding hos-pital mortality and postoperative complications are infavour of endovascular management but no significantdifferences are found in terms of survival at 1, 3 and8 years.ConclusionsConventional surgery in the treatment of thoracic andthoraco-abdominal aortic pathologies also in elderlypopulation may be considered an effective procedure inthe era of stent graft. The aim of further randomizedstudies study is to demonstrate the real superiority ofendovascular procedure over open surgery and to defineits role in the treatment of aortic pathologies especiallyin terms of mid and long-term follow-up.

Preconditioning of isoflurane on spinal cord ischemia can increase the number of inducible nitric oxide synthase-expressing motor neurons in rat

BackgroundSpinal cord ischemia with resulting paraplegia remains one of the most common complications after repair of thoracoabdominal aortic aneurysms or dissection. Inducible nitric oxide synthase (iNOS) is known to have both neuroprotective and neurotoxic effects in the central nervous system. We investigated the possible relationship between the effect of pre-ischemic isoflurane exposure on mild spinal cord ischemia and the inducible nitric oxide synthase (iNOS) expression by using iNOS-specific antibody and pyrrolidinedithio carbamate (PDTC), NF-κB inhibitor, in the ventral horn of spinal cord in rats.MethodsThe animals were divided into five groups (n = 6 in each group): sham group, control group, PDTC-treated group, isoflurane-treated group, and PDTC/ isoflurane-treated group. In the PDTC-treated groups, 2% 100 mg/kg PDTC was administered intraperitoneally at 1 h before operation and at 24 h and 48 h after reperfusion. The rats in the isoflurane-treated groups received 30 min inhalation of 2.8% isoflurane at 24 h before spinal cord ischemia. Immunohistochemistry was performed to detect iNOS expression in the motor neuron of the ventral horn in spinal cord.ResultsPreconditioning with isoflurane increased the iNOS expression when compared to the control group (P < 0.05), whereas pre-treatment with both PDTC and isoflurane significantly decreased the iNOS expression compared to isoflurane-treated group (P < 0.05).ConclusionsPre-ischemic isoflurane exposure was related with increase of the iNOS expression via a pathway modulated by NF-κB. iNOS may act as an important mediator of delayed preconditioning with isoflurane for the protective effect against spinal cord ischemia.

Impaired Systolic Function in Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is a recently described autosomal dominant genetic syndrome caused by mutations in the gene encoding transforming growth factor-β receptor 1 or 21 with no known cardiac involvement. Common characteristics include aortic and arterial aneurysms or dissections, orbital hypertelorism, and cleft palate or bifid uvula. We report the first case of a cardiomyopathy associated with LDS in a patient with a novel transforming growth factor-β receptor mutation and pathological evidence of microvascular coronary artery dysplasia. A 44-year-old tall, thin, white man with “borderline” hypertension and sleep apnea developed a severe, painful stabbing sensation in his throat while walking. He presented to a local hospital and was found to have an acute thoracoabdominal aortic dissection (Stanford type A) without involvement of the coronary …

Hybrid Procedures for Thoracoabdominal Aortic Aneurysms

Treatment of thoracic aortic pathology has been rapidly changing in the 5 years since US Food and Drug Administration approval of thoracic stent grafts. Although not specifically evaluated in any of the major clinical trials to date, adjunctive techniques are being increasingly used to expand the applicability of stent-graft technology to patients with more extensive thoracoabdominal aortic aneurysms and dissections. Details of procedural techniques have been delineated by several aortic specialists, resulting in a trend toward standardization of effective strategies. Despite this trend, significant variability is evident in the outcomes of reported series. The objective of this article is to analyze published reports of hybrid procedures involving complete visceral debranching of the aorta and endovascular exclusion of the thoracoabdominal aortic aneurysms.

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections – A single center experience in 28 patients

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections – A single center experience in 28 patients